summary page general pathology - bc medical qualitybcmqi.ca/published...

Summary page General Pathology

REVIEW PANEL COMPOSITION

The panel was composed of two co-chairs with expertise in the provincial privileging dictionaries and

8 subject matter experts, who work across 7 of the province’s health authorities with representation

of the Doctors of BC

RECORD OF REVIEW PANEL DECISIONS AND CRITERIA IDENTIFIED

Below are panel decisions and/or criteria identified to guide discussion of clinical practice and standards.

1. Refer to the Royal College discipline definition

The panel decided to continue using the discipline definition provided by the Royal College of Physicians and Surgeons of Canada.

2. Use training requirements to define current experience

The panel defines current experience by specifying training requirements associated to each core and non-core privilege. The training requirements replace the procedure numbers that previously defined current experience.

3. Breaking General Pathology Core Privileges into five subdivisions

The decision was made to take the five domains of general pathology and separate them out into 5 core areas: medical microbiology, hematological pathology/ transfusion medicine, medical biochemistry, anatomical pathology, molecular pathology.

4. Add Flow Cytometry as a non-core privilege

Flow Cytometry was omitted from the first version of the dictionary. The panel made the decision to add it as a non-core privilege.

5. Define Molecular Pathology

The panel agreed to accept both standardized definitions for core and non-core Molecular Pathology as recommended by a sub-committee of subject-matter experts.

6. Pediatric pathology fellowship is the requirement for perinatal autopsy and apparently natural

infant or child death

The panel agreed that a pediatric pathology fellowship is the appropriate training for perinatal autopsy and apparently natural infant or child death. Forensic pathology fellowship is not required to provide this service.

The General Pathology dictionary was approved by PMSEC on 9 November 2017


Core Privileges

Decision / Revision: Break core privileges into five subdivisions

Engagement Method: Panel discussion

ORIGINAL REVISION

In the initial version, there was only one core privilege, encompassing all subdivisions

Core privileges:

General Pathology

C1 Break General Pathology into five selectable core privileges:

Core privileges: Medical Biochemistry

Core privileges: Hematological Pathology and Transfusion Medicine

Core privileges: Anatomical Pathology

Core privileges: Medical Microbiology

Core privileges: Molecular Pathology

Decision / Revision: Define autopsy pathology

Engagement Method: Panel discussion and forensic pathologist consultation

ORIGINAL REVISION

Not Applicable

C2 Define autopsy pathology according to General Pathology scope of

practice

*Autopsy pathology is limited to performance of autopsies on individuals

aged 14 or older, and excludes:

All homicides and suspicious deaths

All deaths in custody, or police action-related deaths

Cases with identification issues

Mass fatalities

Etc. Note—for autopsy pathology that is outside of the provider’s

normal scope of practice, seek appropriate subspecialty advice.

Decision / Revision: Molecular Pathology definitions have been defined by a sub panel

Engagement Method: Subpanel recommendation and panel discussion

ORIGINAL REVISION

Not Applicable

Definitions and criteria developed by a sub-panel consisted of experts in

molecular pathology, cytogenetics and molecular genetics. The panel slightly

revised the definition to align with their scope of practice

C3 Core Privileges: Molecular Pathology

Definition: Use of genetic and genomic reports and findings in the practice of

pathology

C4 Non-core privileges: Molecular Pathology

Definition: Interpretation, reporting, documentation and oversight of

genetic and genomic methods and findings in the practice of pathology


Non-core Privileges

Decision / Revision: New non-core privileges - The non-core privileges reflect the pathology scope

of practice.

Engagement Method: Sub-panel recommendation and panel discussion

ORIGINAL REVISION

Not Applicable C5 Definition and criteria developed by a sub-panel consisted of experts in

molecular pathology, cytogenetics and molecular genetics. The panel slightly

revised the definition to align with their scope of practice

Non-core privileges: Cytogenetics

Non-core privileges: Molecular Genetics

Decision / Revision: Include a context specific statement to prompt collaborative practice between

forensic and pediatric pathologists

Engagement Method: Subpanel recommendation and panel discussion

ORIGINAL REVISION

Not Applicable C6 Panel members was in agreement to add a context specific statement to

the following non-core privileges:

Non-core Privileges: Examination for criminally suspicious infant death

Non-core Privileges: Examination for perinatal autopsy and apparently

natural infant or child death (less than 14 years of age)

Context specific statement:

The overlap between suspicious and apparently natural death in a child

under the age of 14 years may not be clear-cut and may require

collaborative practice between forensic and pediatric pathologists.

General Pathology Clinical Privileges

This dictionary is copyright protected 11-2017 PHSA. For information contact [email protected]. 1

Name:

Effective from / / to_____/_____/_____

❏ Initial privileges (initial appointment)

❏ Renewal of privileges (reappointment)

All new applicants must meet the following requirements as approved by the governing body,

effective: November 9, 2017

Instructions:

Applicant: Check the “Requested” box for each privilege requested. Applicants are responsible

for producing required documentation to allow for a proper evaluation of current skill, current

clinical activity, and other qualifications and for resolving any doubts related to qualifications for

requested privileges. Please provide this supporting information by uploading the appropriate

documents. Privileges should not be requested (checked off) and cannot be granted unless the

specific criteria associated with the privilege are met.

Medical/Clinical leaders: Check the appropriate box for recommendation on the last page of

this form and include your recommendation for any required evaluation. If recommended with

conditions or not recommended, provide the condition or explanation on the last page of this

form.

Current experience: Current experience thresholds suggested in this document were

developed by practitioners in the field, and are not intended as a barrier to practice or to service

delivery. They are not intended as rigid cut offs, below which clinical privileges must be

restricted or removed. Instead, medical/clinical leaders are encouraged to initiate discussions

with those practitioners who are close to or below the thresholds, to ensure that mechanisms

are in place to ensure adequate practitioner experience and patient outcomes.

Other requirements: Note that even if applicants meet skill or experience requirements, each

site will determine if the requested privilege can be supported at that site. Privileges granted

may only be exercised at the site(s) and/or setting(s) that have sufficient space, equipment,

staffing, and other resources required to support the privilege.

This document is focused on defining qualifications related to training and current experience to

exercise clinical privileges. The applicant must also adhere to any additional organizational,

regulatory, or accreditation requirements that the organization is obligated to meet.

Context: The care of patients presenting with complex problems or uncommon diseases

requires access to multidisciplinary groups, experienced teams and institutions with the

necessary subspecialties and infrastructure for appropriate care.

Grandparenting: Practitioners holding privileges prior to implementation of the dictionary will

continue to hold those privileges as long as they meet current experience and quality

requirements.

mailto:%[email protected]



Continuous Professional Development (CPD): Where suggested in this document, CPD

requirements reflect those professional development activities which are eligible for:

1. credit under the Royal College of Physicians and Surgeons of Canada’s (Maintenance of

Certification (MOC) program;

2. the College of Family Physicians of Canada Mainpro+;

3. those professional development activities held in foreign jurisdictions which would be

eligible under the MOC/Mainpro program if held in Canada; or

4. equivalent CPD or Quality Assurance activities for other practitioners.

Planned vs. Unplanned (Emergency) Care: The scope of privileges granted to any individual

practitioner is based on considerations of patient care under “normal circumstances.” In the

setting of risk to life or limb, the rules of privilege are not meant to constrain practitioners from

acting in the best interest of a patient.

Note: The dictionary will be reviewed over time to ensure it is reflective of current practices,

procedures and technologies.

Core privilege: Types of activities a recent graduate of the discipline can reasonably be

expected to perform at a specific facility. Under core privileges in this dictionary, if there is a

procedure you wish to NOT perform please type into the Comments field.

Non-core privilege: Types of activities that require further training, experience and

demonstrated skill. Non-core privileges are requested in addition to requesting core. Individuals

requesting these privileges should meet the specific threshold criteria associated to such non-

core privileges.

Context specific privileges: Privileges that take into account what medical services and

procedures a facility can support.

Additional privilege: An additional privilege is any privilege that is not included in the core,

non-core, or context-specific privileges dictionary for your discipline. Additional privileges

already listed in this document were previously requested by others who practice in your

discipline; they may or may not be relevant to you. If there are any privileges not listed in your

dictionary that you wish to request, please complete an additional privilege request form and

attach any evidence of training to support your request.

Restricted procedures: Some dictionaries have procedures identified by the Ministry of Health

as [DESIGNATED A RESTRICTED SERVICE BY THE MEDICAL SERVICES COMMISSION].

Privileges identified as restricted procedures may be flagged in this document. Where it

appears, the restricted procedures flag is for administrative tracking only, and has no impact on

clinical content.




Definition

A General Pathologist is a specialist who is trained in diagnosis and in laboratory management,

incorporating and integrating all aspects of laboratory methodology, playing a key role in quality

assurance and the introduction of emerging technologies. This includes providing consultation

to medical colleagues using morphologic techniques such as histopathology, cytology, autopsy,

forensics and clinical laboratory methods, namely biochemistry, laboratory hematology, blood

transfusion and microbiology. General Pathology is distinct because the training is divided

between Anatomical Pathology and clinical laboratory medicine. General Pathologists are

trained to practice in a variety of settings including large metropolitan, regional, and community

hospitals, and may play a role in teaching or research. General Pathology can also be a route

for sub-specialty or diploma training.

Qualifications for General Pathology

Initial privileges: To be eligible to apply for privileges in General Pathology (anatomical,

clinical), the applicant should normally meet the following criteria:

Certification in General Pathology by the Royal College of Physicians and Surgeons of Canada

or be recognized as a general pathologist by the College of Physicians and Surgeons of British

Columbia by virtue of credentials earned in another jurisdiction that are acceptable to both the

College and the Health Authority and its Affiliate(s).

AND

Required current experience: Full- or part-time pathology services, reflective of the scope of

privileges requested, for the past 12 months or successful completion of an RCPSC or

equivalent accredited residency or clinical/research fellowship immediately following

residency within the past 12 months.

Renewal of privileges: To be eligible to renew privileges in pathology, the applicant should

meet the following criteria:

Current demonstrated skill and an adequate volume of full- or part-time experience with

acceptable results, reflective of the scope of the privileges requested, (minimum of 24 weeks

working in the discipline for the past 36 months) based on results of ongoing professional

practice evaluation and outcomes.

A General Pathologist may be expected to have expertise in all four disciplines of laboratory

medicine. Where a pathologist’s experience in the past three years for a requested privilege is

determined insufficient by regional department head or equivalent to maintain skill, privileges

will be renewed following the completion of a period of education prescribed by the regional

medical director or delegate for laboratory medicine. Any education prescribed will be done

under the auspices of a facility that is regularly engaged in the training of laboratory medicine




residents, and will be signed off by the medical director/ department head of that

facility/program.

Return to practice: Individualized evaluation at an academic training center that trains

Pathology residents, with supervision of core procedures relevant to their intended scope of

practice.

Core privileges: Medical Biochemistry

❑ Requested

Patient diagnosis, ordering investigations, consultation, and laboratory medical oversight in

medical biochemistry. The core privileges in this specialty include the core procedures on the

procedures list near the end of the document and such other procedures that are extensions

of the same techniques and skills.

Clinical consultation and interpretation in nutrition, cancer-associated biochemical abnormalities, therapeutic drug monitoring, pediatric and prenatal clinical biochemistry.

Apply laboratory techniques of medical biochemistry for diagnosis and management of disease for patients of all ages with a variety of metabolic disorders and biochemical abnormalities.

Medical oversight of a clinical pathology laboratory

Core privileges: Hematological pathology/Transfusion medicine

❑ Requested


hematological pathology and transfusion medicine. The core privileges in this specialty include

the core procedures on the procedures list near the end of the document and such other

procedures that are extensions of the same techniques and skills.

Clinical consultation and interpretation of investigations of conditions affecting blood, bone marrow, lymph nodes, and spleen

Clinical consultation and interpretation of investigations involving transfusion of blood and blood products

Stewardship over appropriate use of blood and blood products


Core privileges: Anatomical pathology

❑ Requested




Patient diagnosis, ordering investigations, consultation, and laboratory medical oversight in:

anatomical pathology, including surgical pathology (including intraoperative consultations),

cytopathology, autopsy pathology*, immunohistochemistry, and associated ancillary studies. The

core privileges in this specialty include the procedures on the attached procedures list and such

other procedures that are extensions of the same techniques and skills.

*Autopsy pathology is limited to performance of autopsies on individuals aged 14 or older, and

excludes:

All homicides and suspicious deaths

All deaths in custody, or police action-related deaths

Cases with identification issues

Mass fatalities

Etc. Note—for autopsy pathology that is outside of the provider’s normal scope of practice, seek appropriate subspecialty advice.

Core privileges: Medical microbiology

❑ Requested


medical microbiology. The core privileges in this specialty include the core procedures on the

procedures list near the end of the document and such other procedures that are extensions of

the same techniques and skills.

Clinical consultation and interpretation of investigations for conditions involving infectious diseases


Clinical consultation regarding antimicrobial stewardship and infection control

Core privileges: Molecular pathology

❑ Requested

Use of genetic and genomic reports and findings in the practice of pathology

Core procedures list for general pathology

This is not intended to be an all-encompassing procedures list. It defines the types of activities/

procedures/privileges that the majority of practitioners in this specialty at this organization would

competently perform, and inherent activities/procedures/privileges requiring similar skill sets and

techniques.

To the applicant: Select the following procedure(s) you wish to perform.




Core privileges: Bone marrow aspiration and biopsy procedures

❑ Requested

Bone marrow aspiration and biopsy procedures

Core privileges: Fine Needle Aspiration

❑ Requested

Performance of fine needle aspiration

Non-core privilege: Examination of human skeletal remains

❑ Requested

Initial privileges: Requires completion of a recognized postgraduate fellowship in forensic

pathology

OR

Other recognized experience or training in human skeletal remains, suitability to be assessed by

the appropriate medical leader as per Medical Staff Bylaws and Rules within each health

authority

AND


privileges requested, for the past 12 months or successful completion of postgraduate fellowship

in the past 12 months.

Renewal of privileges: To be eligible to renew this privilege, the applicant should meet the

following criteria:


acceptable results, reflective of the scope of the privilege requested, (minimum of 24 weeks



Non-core privileges (see specific criteria)

Are permits for activities that require further training, experience and demonstrated skill.

Are requested individually in addition to requesting the core.

Each individual requesting non-core privileges should meet the specific threshold criteria as outlined.






practice

Non-core privilege: Examination for criminally suspicious infant death

❑ Requested

The overlap between suspicious and apparently natural death in a child under the age of 14

years may not be clear-cut and may require collaborative practice between forensic and

pediatric pathologists.

Initial privileges: Requires completion of a recognized postgraduate fellowship in forensic

pathology.

OR

Other recognized experience in infant autopsy pathology, suitability to be assessed by the

appropriate medical leader as per Medical Staff Bylaws and Rules within each health authority

AND

Required current experience: Full- or part-time pathology services, specific to infant autopsy

for the past 12 months or successful completion of postgraduate fellowship in the past 12

months.


following criteria:







practice

Non-core privileges: Examination for perinatal autopsy and

apparently natural infant or child death (less than 14 years of age)

❑ Requested

Note: For autopsy pathology that is outside of the provider’s normal scope of practice, seek

appropriate subspecialty advice




The overlap between suspicious and apparently natural death in a child under the age of 14

years may not be clear-cut and may require collaborative practice between forensic and

pediatric pathologists.

Initial privileges: Requires completion of a recognized postgraduate fellowship in pediatric

pathology

OR

Other recognized experience in pediatric autopsy pathology, suitability to be assessed by the


AND

Required current experience: Full- or part-time pathology services, specific to infant/child

autopsy practice and including pediatric-specific CME and quality assurance activities, for the

past 12 months or successful completion of postgraduate fellowship in the past 12 months.


following criteria:







practice.

Non-core privileges: Flow Cytometry

❑ Requested

Initial privileges: The applicant has completed training to the satisfaction of the


AND


privilege requested, for the past 12 months or successful completion of postgraduate fellowship



following criteria:










practice.

Non-core privileges: Immunofluorescence

❑ Requested

Initial privileges: The applicant has completed training to the satisfaction of the appropriate

medical leader as per Medical Staff Bylaws and Rules within each health authority

AND





following criteria:







practice.

Non-core privilege: Molecular Pathology

Definition

Interpretation, reporting, documentation and oversight of genetic and genomic methods and

findings in the practice of pathology

❑Requested

Initial privileges: The applicant has completed training to the satisfaction of the appropriate

medical leader as per Medical Staff Bylaws and Rules within each health authority

AND








following criteria:







practice.

Non-core privileges: Cytogenetics

Definition

Cytogenetics is a branch of laboratory medicine concerned with the study of chromosomes and

how chromosomal anomalies relate to human disease and phenotype. (Defined by the

Canadian College of Medical Geneticists)

❑Requested

Initial privileges: The applicant has completed additional training or equivalent and is certified

by the Canadian College of Medical Geneticists or American Board of Medical Genetics and

Genomics in Cytogenetics

Non-core privileges: Molecular Genetics

Definition

Molecular genetics is a study of molecular diagnostic testing techniques used for disease

diagnosis, including the identification and interpretation of molecular abnormalities, and

participation in the management of patients and their families with molecular genetic disorders.

(Defined by the Canadian College of Medical Geneticists)

❑Requested

Initial privileges: The applicant has completed additional training or equivalent and is certified

by the Canadian College of Medical Geneticists or American Board of Medical Genetics and

Genomics in Molecular Genetics




Context specific privileges: Administration of procedural sedation

❑ Requested

See “Hospital Policy for Sedation and Analgesia by Non-anesthesiologists.”

Context Specific Privileges

Context refers to the capacity of a facility to support an activity




Additional privileges Definition: An additional privilege is any privilege that is not included in the core, non-core, or context-specific privileges dictionary for your discipline.

Instructions

On the additional privilege request form, you’ll be asked to provide the following details:

a) the privilege requested (the procedure or activity you are requesting)

b) the site or facility where the privilege would be exercised, and

c) your relevant training, experience or certification, if applicable.

Your request for additional privileges will be submitted to your medical leader. Please note that additional privileges are not automatically granted, but are reviewed to determine alignment with the site capacity and to ensure training requirements are met.

The privileging dictionaries on this site (bcmqi.ca) are the official versions.

Dictionary content will be updated as according to the review schedule posted at the bcmqi.ca dictionary review hub. You can provide input on a dictionary at any time, by submitting a Dictionary Feedback form to the BC MQI office.

Dictionary content and feedback

To request a privilege that is not included in the core, non-core, or context specific

privileges for your discipline, notify your medical leader or local credentialing office.

A credentialing coordinator will send you an additional privilege request form to complete.


http://bcmqi.ca/

http://bcmqi.ca/credentialing-privileging/dictionaries/dictionary-review-hub

http://bcmqi.ca/dictionary-feedback



I have requested only those privileges for which by education, training, current experience, and demonstrated performance I am qualified to perform and for which I wish to exercise at the facility I am applying, and I understand that:

a. In exercising any clinical privileges granted, I am constrained by hospital and

medical staff policies and rules applicable generally and any applicable to the

particular situation.

b. Any restriction on the clinical privileges granted to me is waived in an emergency

situation, and in such situation my actions are governed by the applicable section of the

medical staff bylaws or related documents.

Signed: ____________________________ Date: _____________________________

I have reviewed the requested clinical privileges and supporting documentation for the above-named applicant and:

❑ Recommend all requested privileges

❑ Recommend privileges with the following conditions/modifications:

❑ Do not recommend the following requested privileges:

Privilege condition/ modification/ explanation

Notes:

Name of Department / Division/ Program/ Facility:

Name of Medical Leader:

Title:

Signature:

Date:

Acknowledgement of Practitioner

Medical / Clinical Leader’s Recommendation

S


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